-carch revealed malignant tertian parasites and quinine treat-s resumed
;
and, with the exception of a slight rise on the,1 ague on May 4th an< 7th, no more fever occurred : theimproved, and he left hospital on May 18th, the case at tinsiving been one of biliary colic complicated by malarial fever.•ember 18th. 1902. he returned to hospital, and came under my1 since 7th in bed. Has passed severa gall stones since theich lie brought with him. the largest being about Jin. inThe liver dullness extended from the fourth space to 3 in.c costal margin. Spleen not enlarged, well-marked jaundiceh pain of a colicky nature requiring morphine. TemperatureP to 102
0
, with profuse perspiration./er continued, and on December 22nd he coughed up a quan-scid frothy mucus. Temperature, of a hectic type, continued
103
0
and 104
0
in the evening. The vocal fremitus was slightlycd, but there was only partial loss of resonance at the rightdiagnosed suppuration in the bile ducts in the liver, andiperation for the purpose of draining the ducts and removingstones. After a consultation
vthis
was agreed to. On the morn-e
25U1
he coughed up a small quantity or pus, but in view of thentioncd above, in which a fatal termination ensued in anof this kind, in spite of the opening tlirough the lung, and•ertain knowledge of gall stones having been passed, it wasto proceed with the operation as previously arranged. Captainin, I.M.S., kindly helping me.
inn.
—An
incision was made in the right linea semilunaris with
(3
over the lower edge of the liver. The gall bladder was com-liddcn beneath the edge of the liver, but its fundus was reachedued, and a number of small gall stones were extracted. On.•sing the finger along the bile ducts beneath the liver, a largegall stones were felt deep under the liver, which could onlycached. The wound was now enlarged upwards and downwards,transverse incision made across to the middle line, so asle the lower edge of the greatly enlarged liver to be
up.
The mass of stones in the right hepatic ductsow be reached and opened, and with very considerable• a mass of large gall stones, some 3 in. in length and over andiameter in places, were removed, some of which were welliu liver substance.
As
it was quite impossible at such a depth to
•
opening in the duotto the surface, andas the patient was in a-, a glass drainage tube was inserted and gauze carefully packedt and the wound united around the tube. The patient sufferedfrom shock, but rallied somewhat in the afternoon, but wasmoled by coughing up mucus. At 10 in the evening he wasnd coughing up mucus more easily. However, he never fullyrom the shock of the prolonged operation and died at 5.30 a.m.••;/•—The same morning the body was examined. There were:<.>od adhesions around the gauze packing and no trace of leak-; »charge into the peritoneal cavity. The liver was removedstomach and duodenum and rig-lit lung altogether. Only one
U
stone in the depth of the liver in ¡the right hepatic duct wasInch was much smaller than some of those removed at then. so would easily have escaped through the opening made in;. and would doubtless have escaped through the wound,1 too deep in the liver to
b<?
removed at the operation. Behind)C the bile ducts were much dilated and full of pus in a limitedof the upper posterior portion of the right lobe of the liver,eking abscess had opened posteriorly by the side of the inferiora. and travelled up through the diaphragm and the base of theig into the inferior bronchi. The common bile duct was dilated,jpeuing into the duodenum was large and free.
is case a correct diagnosis of suppuration in the intra-bile ducts was made very shortly after admission, andration undertaken without any unnecessary delay,eat enlargement of the liver and depth of thein its hilum caused unusually great difficulty, yetets were completely cleared with the exceptionsmall stone mentioned, and but for the unfor-'»pening of the tracking abscess into a bronchus on the
1?
arranged for the operation leading to a serious extrathe patients strength in coughing up the muco-pus, I
}
favourable result might reasonably have been hopedile the conditions revealed
post
mortem
clearly showed•thing short of removal of the stones impacted in the
•
ducts, and free drainage of the pus-distended intra-
•
ducts, could have relieved the symbtoms and avertedil termination of this very deadly affection. In short,case had come under my care a week earlier his lifelavejbeen saved by a still earlier operation, which empha-se importance of early diagnosis with a view to veryperation.>ve not had
.
time to search the literature of thew years for cases of this nature, but I think thatrate cases in which suppuration in the intrahepatic
ave
£?en diad d ti dtk ithuppuration in the intrahepatic
av
.
e
£?en diagnosed and an operation undertaken withct object of draining the abscess through opening the
-•ts
are:sufficiently rare to be worth placing on record,e cases are quite, distinct from,.and require totally
1
operative treatment to, the ordinary amoebic tropicalLÀTHYRISM.By Major A. G.
HENDLEY,
I.M.S.
THE
best definition of this affection is Scheube's, which notonly sums up in a few words prevalent opinions as to itscausation, but at once recalls the nature of a too narrowly-known disease of importance. He says
:
" Lathyrism is adisease of the nature of an intoxication with a spastic spinalparalytic course, which is attributable to poisoning withvarious kinds of the family of
Papilionaceae
lathyrus
(chick-pea or common pulse).Dr. Watts, in his
Dictionary of the
Economic Products
ofIndia,
says : " Lathyrus, a genus of annual or perennial plantof the natural order
• Leguminosae,
which comprises some 170species, seven of which are natives of India." The specimensI have here are of the commonest cultivated Indian variety,lathyrus sativus, known in different parts of India undervarious vernacular names, as
khesán dáll, teóra, lákh,
or
lákhóri.
To quote Dr. Watts again: "Lathyrus sativus(jarosse or gesse) is indigenous from the Southern Caucasus toNorthern India
;
it has spread as a weed of cultivation fromits original home, and is now cultivated all over India." Inthe Central Provinces some 358,000 acres are under lathyruscultivation ; and it is in these provinces that the disease hasof late years become so increasingly prevalent as to call forGovernment inquiry, which inquiry his been entrusted toMajor Andrew Buchanan, I.M.S., who has for the past sixmonths or more been devoting his entire attention to thissubject.
History.
Lathyrism is no newly-discovered affection. Its historydates from very early times, being, according to Huber,alluded to in the Hippocratic writings, where mention ismade of the fact that " At Ainos those men and women whocontinually fed on pulse were attacked by a weakness in thelegs which remained permanent." In Don's
System ofGardening,
again, it is recorded, in describing lathyrussativus, that
:
" In several parts of the Continent a whitepleasant bread is made from the flour of this pulse, but itproduced such dreadful effects in the seventeenth centurythat the use of it was forbidden by an edict of George, Dukeof Wurtemberg, in
1671,
which was enforced by two otheredicts under his successor Leopold in
1705
and 1714." InItaly and France the disease was also observed during theseventeenth and eighteenth centuries, and in the earlier halfof the nineteenth century, large numbers of persons becomingaffected in France, British India, and Algiers, attractedapparently some considerable attention. From the years1857-68, when Dr. James Irving—then Civil Surgeon ofAllahabad—contributed five very interesting and exhaustivepapers to the
Indian Annals of
Medical Science
on the subjectof an epidemic of lathyrism then prevailing in the North-,West Provinces, down to 1893, when I described in the
Indian
Medical Gazette
a localized outbreak I had met within the Central Provinces, the disease seems to have attractedno notice, save at the hands of a few veterinary surgeons,who noted its effects on cattle, and may in consequence beassumed as practically non-existent. The circumstancesunder which I first made acquaintance with the affectionwere as follows :Towards the end of July,
1893,
I came across a village wherequite suddenly some
10
per cent, of the male population hadduring the previous five or six weeks (that is, since the com-mencement of the rainy season) become paralysed, more orless severely, in the lower limbs. At that time I had neverheard of such an affection as lathyrism, but careful investiga-tion and inquiry into the circumstances of the outbreak soonconvinced me that they owed their condition to poisoningwith lathyrus sativus, a pulse on which all the affected, poorhand-to-mouth labourers had largely subsisted for someeighteen months on account of the failure of their moreregular crops, in consequence of which the village landlordhad paid his labourers in kind with the cheapest grain avail-able—namely, lathyrus sativus. For some years I saw nofurther case of this disease; but with years of scarcityculminating in the terrible famine of 1896-7, the local condi-tions artificially produced by the village-landlord m 1893became general-; the poorer agricultural labourers were drivento resort extensively to the cheapest foodstuff procurable(lathyrus), and with most disastrous consequences. In theaverage• village a dozen or more victims would be found,,whilst in a famine relief camp of some 4,000 persons itbecame easy to pick out one or two hundred such cases.
>
The disease has, in the Central Provinces, and adjoining
70S
-»~j
ÍÁTHYRISM.native States, gone on spreading ever since, helped by thesecond severe famine of 1899-1900; until at the present timeMajor Buchanan writes to me that he has an incomplete•census of 2,700 cases in one district and
1,400cases
in another
;
and in a recent letter says, "I have seen 190 cases thismorning."
Symptoms.
I will now pass on to a description of the symptoms andmode of onset of the disease. For reasons, given above, itwill be seen that only the poorest classes are liable to thisdisease
;
those who are forced to subsist on the grain un-mixed or diluted only slightly with other grain. All theaffected will be found to belong to this class. They eat iteither ground into flour as bread, cooked as porridge¿ orboiled with or without oil as lentils, much as we eat haricotbeanp. Practically all are field labourers, and the wonderfulunanimity with which all agree as to the onset of the diseaseis most striking. A man will say,
'•
I went to sleep perfectlywell and very tired after a day's ploughing or other field workin the rain (it is always in the rainy season) and awoke inthe morning to find my legs
stiff,
weak, trembling, and veryheavy to lift when I rose to walk."
ÇL
have never been ableto-elicit any history of premonitory symptoms.) This weak-ness and trembling, you will be told,.increased so rapidlythat within ten
days
progression became difficult, even withthe aid of sticks. Still the patients have no sense of illnessand no pain; they have good appetites, sound digestions.• and natural sleep at night. Both legs are usually affectedsimultaneously, first the calves, then the thighs, and soonafter this all sexual appetite and power was lost. All com-plain bitterly of this. •On examination of any typical case, of some six weeks'duration, you will find that the gait is very peculiar. Aided
•
with a long two-handed staff walking is possible, the rate ofprogression being under two miles an hour. The body abovethe liips sways from.side to side, whilst the feet, which seemclogged with invisible weights, are lifted with.evident diffi-culty and dragged forward, the toes scratching along or barelyclearing the ground. The leg bearing the weight of the bodyis bent at the knee and trembles, whilst the advancing leg,dragged wearily forward strongly adducted, is planted un-steadily directly in front of its fellow, the toes reaching theground first. In short a kind of paralytic goosestep. Thegeneral effect is one of laboured unsteadiness, due to greatweakness. The evident spasm of the thigh adductors ceasesto be very apparent when the patient reclines on his back,when the thighs can be separated, usually without resistance,to a normal extent. There is no wasting, no loss of musculartone, no true tremors, only tremblings of the entire limbswhen weight is put.oD them. Sensation seems quite un-affected. The tendon reflexes are much exaggerated, bothknee-jerk and ankle-clonus
;
the slightest stimulus startingthe latter phenomenon going for a long time. There is noloss of power or undue excitability in bladder or rectum.The arms, trunk, head and neck muscles are unaffected. Themind is clear, speech natural, pupils normal and reactingnaturally to light and accommodation. The urine is often ofrather high specific gravity (1030), acid, and contains abundanturates. ouch are the symptoms as I have found them. I amaware that some writers state that digestive disturbances,colicky pains, and diarrhoea are usually precursors of theparalytic state
;
and that sensory disturbances such as hyper-aesthesia, anaesthesia, and formication, with bladder troubles,such as incontinence and retention of urine, are common. Ihave never met with a case in my experience of manyhundreds where the slightest history or evidence of any suchcomplications could be traced.
Etiology.
As regards the etiology of the disease, it is, I think,generally conceded now that the paralysis is in some way dueto lathyrus poisoning.. Other mam theories of causation are :
1. That latbyrus eating has nothing to do with it.' 2. That if it has, it is only diseased grain which is capable ofpoisonous effects.
-
-:
3. That exposure to sun or some local hot wind is the true cause.
4.
That the paralysis is due entirely to cold and damp.
5.
One eminent authority on tropical medicine (Manson') has thrownout the suggestion that, like alcoholism and probably bert-bcri, thedisease may be due to the entrance into the body of a toxin'gen orated bygerms-whose habitat is outside the body.' 6. Lastly, I am quite prepared to hear some champion of parasitismarise and suggest that some organism, so minute as to have hithertoescaped observation, is really the author of all the
mischief.
•.. In the time at my disposal I cannot fully discussthese andother theories, and can only say that the oecurrenppdisease in epidemic form among lathyrus eaters andno others, seenis to me very strong evidence that a
IT
diet is primarily responsible. The idea that diseasedonly is injurious is an argument probably borrowed froanalogy of ergotism. I know of no facts to support thThat exposure to sun or some local hot wind can
h
i
ÎÂ
responsible is at one disproved by the undoubted fact tli 11¿disease has occurred (amongst lathyrus eaters) equally r
i ife
(g y s)
equally
]
trously in India, Italy, France, Algiers, and Wurt^ml
ÏÏZ
countries with vastly dissimilar meteorological condiii'n
Also,
if exposure to cold and wet alone could induce
l
Eld l hld b fll f hy y, , g, d Wurt^ml
ÏÏZ
countries with vastly dissimilar meteorological condiii'nAlso, if exposure
to cold
and wet alone could induce latln-riamEngland surely should be full of such cases. As n'tmrd'Manson's suggestion that the affection, like beri-beri mavS»a "place disease," one has only to remember that thparalysis is incurable, and that removal from the locallt»where the person was attacked is in no sense beneficial JJto what the actual poison is, and how it acts, that is a matterstill left for our eminent physiologists and chemists
to
decid?Church has stated the chemical composition of the grain at»water, 10.1; albuminoids, 31.9; starch and fibre, 53.9;
o
n*0.9
;
ash, 3.2
;
and has further observed that " the oOexpressed is a powerful and dangerous cathartic." -,Astier says " there is present in the grain a volatile liqnifl
alkaloid, probably produced by some proteid ferment, whichexhibits the toxic action of the seeds, and the action of Jwhich is destroyed by heat." On this volatility and destredï/Htion by heat notion has been based much speculation as
i&
'
;
S
possible variations in methods of cooking, explaining
flit ?
eaprieiousness of the effects of a diet of this grain
on
difieren
ït
1
individuals. Scheube says, "Several poisonous alkalokihave been extracted but further investigations are necessary^
also,
" that by the administration of preparations made frwthe grain, a disease giving rise to symptoms similarlathyrism has been produced in animals."Professor Dunstan, of the Indian Institute, is now working?at this subject. So far his investigations and experiments oaanimals are inconclusive, but go to show
(1)
That only certala.*samples of lathyrus are poisonous
;
(2) there are some reason to think the poison is contained in the skin or husk of th»seed, but no fungus has been discovered
;
(3) that poultry
ax J
immune, but that rabbits and guinea-pigs are sometime»-* affected. Professor Dunstan also tells me that in Canadlathyrus is largely grown and freely used as poultry food,probably birds are immune. My own pigeon feedingexperiments in India were all negative and so support thisview. 4There remain two points of interest in connexion withcausation of lathyrism, namely, its marked preference /;males and its seasonal incidence, that is, during the rainyseason. Dr. Irving found that the proportion of females to:males attacked was about 1 in 12. Major A. BuchanaaÇ^jI.M.S., with a recent very large experience, tells me he findüíit
1
in 10. I personally have only seen
3
female cases against vmany hundreds of males. Major Buchanan accepts the con****-parative immunity of females as an unexplainable fact,says that the reason for the seasonal incidence of th diseis very simple, namely, that "he finds that thegrain pits or granaries are closed in June, andgrain is only issued to labourers in the rains." . i*1The difficulty in the way of accepting this explanation
1»;
that (1) I do not believe the custom he alludes to is genetU'j—that of only eating lathyrus during the rains—it certainlyjwas not during the recent famines
;
and (2) the fact
l°**¡
according to this idea cases occurring quite early in hiemust have been caused by a very few days' dietary of tn»jpoison
;
and this is opposed to all my experience of histonej|given me by patients. I prefer an even simpler solutionboth difficulties. As long ago as
1858
Dr. Irvine quoted*prevalent opinion amongst intelligent educated nativesbeing, that "the lameness produced by eating latbyjus«really a mixture of palsy and rheumatism," and added 1seem to think that living on this particular grain is thedisposing cause, and exposure to cold, rain, and damp^eatthe exciting cause."
T
vwrI believe the native idea is the correct one. I Denevelathyrus, whilst it may possibly cause paralysis by iordinarily only predisposes to it, that it makes the anr.?ady or ripe for the attack of paralysis, but that ezto severe wet and cold is required actually to exea tesudden seizure. This seems to me to explain the unving history of the sudden unexpected attack during
w
season only
;
for nearly
always
the attack
oc^^Jr^
usually thorough wetting whilst ploughing, watching c
thai
te.
i*
.
h
,
or
other field work that ordinarily falls to man's lot
L
d
not to woman's.
To
Lheir greater protection from severend prolonged exposure alone,
I
believe, women
owe
theiriîomDarative immunity.
I
have suggested
to
Major Buchananthat
the
respective shares which exposure
and a
lathyrusdietary have in producing the paralysis might well be testeddurinethe extensive animal-feeding experiments which are tobe carried out
at
the Bombay Research Laboratory.
Morbid Anatomy and Pathology.
Satisfactory observations on the morbid anatomy and path-ology
of the
disease
are
wanting. From
the
clinical sym-ntoms one would be justified in assuming
it to
be
a
form
of
lateral sclerosis, but in "Watts's
Dictionary
I
find
a
statementthnt
•'
Cantarri of Naples has published a number of cases
in
which he has carefully observed
the
conditions after death.Jio nllection of the spinal cord was discovered.
The
musclesof the lower extremities, especially the abductors, were foundto have undergone
a
fatty degeneration, etc." Scheube men-tions
one
published necropsy (where death resulted frommalarial cachexia) where '
' a
softening of the spinal cord abovethe lumbar enlargement was found." Allbutt refers
to two
examinations
of
horses which
had
died
of
lathyrus poison-ing. In these the symptoms were apparently mainly those ofenrdiac and respiratory oppression, and after death "the mis-chief was found mainly;in the cells
of the
anterior horns ofthe cord, which were diminished
in
number and atrophied.There was also thrombosis of small arteries, which were alsothickened. There
was,
too, fatty degeneration of the heart andintrinsic muscles of the larynx." From this he suggests thatthe nerve mischief may be secondary to
the
vascular lesions,which would suggest
a
similarity to ergotism. The prognosisof this disease as regards life
is
favourable.
It
does not seemto cause death directly, but the paralysis
is
incurable. Treat-ment,
I
believe, is quite futile.A PLEA
FOR THE
PROPER MEDICAL SUPER-VISION
OF
"REFRESHMENTS" PURVEYEDON RAILWAYS
IN THE
TROPICS
:
WITH SPECIAL REFERENCE TO INDIA, AND
FOR
BETTER LATRINEAND LAVATORY ACCOMMODATION
FOR THE
TRAVELLING INDIAN PUBLIC.
By H. D.
MCCULLOCH,
M.B.,
Chief Medical Offleer, N.G.S. Railways, India.
OUR
vast Imperial commerce
and the
foreign enterpriseswhich have come into being since
the
introduction
of
steamas a motive power, our great mercantile marine and extensiverailway communications, extending
in
India alone
to
over26,000 miles,
has
resulted, among other things,
in
rapid
in-
tercourse between East and
West.,
which in its turn has goneto bring into prominence certain disadvantages, having
re-
gard
to the
public health
of the
communities concerned,hitherto remote from
one
another. Contingencies havearisen necessitating
the
adoption
of
special precautionarymeasures to prevent the conveyance of infection from already"»•ected areas to uninfected areas.
Owing
partly to the infection being undetectable during thelatent period
in
man
and the
vitality
of the
virus undervarying conditions, climatic
and
otherwise,
the
difficultiesexperienced by medical authorities in the framing and adop-
A
°ru
BaXL
}^
SLr
y
preventive regulations have been very great,ana
the
inconvenience
to the
general public extremely«'Kaome, at these times of panic,
the
consequence being
the
aDandonment of such regulations
or
their irregular adoptionm certain areaè "pro forma,"
and the
adoption
of
serumJjjoculations
of
Haffkine's antitoxin systematically and on
a
•arge scale, by the temporary employment of a large superior«n«ueal
aud
sanitary
staff,
with
the
greatest benefit, where
5
a
*
iterated
ed'
6 nec
essary last year for the Home Government tondia
a
special railway expert
in
administrativeand Mr. Thomas Robertson, C.V.O., was selected asZ^^i^Daniissioner
to
inspect
and to
report
on the ad-
"«iwwations
of
railways in India from
the
commercial
and
^«nonucaspectB, though the administrations
of
the variousie marine companies
in
which
our
Government
is
£î?
c
Î
ly
interested was not included."
™***t
Mr.
Robertson's report was,
I
believe,m india last May, but the Blue Book to be issued
r*?
m
^
01
*
1
'
8t
n
***
the
hands of the King's printers.irom an Indian newspaper article on
"
Indian Rail-way Defects," referring to the very candid report of the SpecialCommissioner, he is represented as having stated that, speak-ing generally,
he
thought
the
present administration
and
working
of the
Indian railways cannot be regarded as satis-factory, etc. He advocates the provision of dining cars on allfast through-service trains to economize time, and thinks thatrailways in India are not sufficiently appreciative of the valueof their third-class passenger traffic, drawing special attention'to certain gross abuses
to
WhicK these
are
subjected.
He
further suggests
the
introduction
of
electric fans, which hethinks should
be
made compulsory within five years
; the
use
of oil
sprinklers
to
állay-dust, and lavatory accommoda-tion
in all
third-class carriages, which should
be
widened.Beyond these important sanitary recommendations
no
reference
is
made
to the
medical departments ofTfcailways,this being, perhaps,
a
matter beyond the; province
of his
report.
.
•''"."' "
:Vv
'
:
\"j
J
'"
The Government
of
India, however,
in
the PubH'c WorksDepartment addressed
the
different railway administrationsthrough the local governments last year desiring thaï certainrules should
be
formally agreed to between the.medical andsanitary authorities
of
local governments and th'ose of rail-ways within their areas,
for
the purpose
1
of
affording suchmutual advice, support,
and
intimation
of
outbreaks- ofepidemics,
etc., as may be for the
general benefit
of the'
public health
and for the
prevention
of
much, siëkness andmortality. ,'.'•'•
.. \ ,
"While these rules
are
having
the
consideration
of our
Government the proposition that
I
would venturero advanceis
the
necessity for adequate medical and sanitary staffs riotonly on our great Indian railways, but also on our mercantilemarine,
to
enable them
to
cope with modern sanitary andmedical requirements,
the
urgent need
for
which
the dia-
f
rammatic representations belowwill,I think,make obvious; andtrust that the time has now come for our medical membersof Parliament, aided by the General Medical Council, to urgethe Government
to
send
out a
Special Commissioner
and
medical expert
to
inspect
and
report upon
the
medicaladministrations
of our
mercantile marine and great railwaysin the interests
of
public health
Diagrams representing inequality
and
inadequacy of
Sup.Medl.
Staffs on Rys.
Miles
3000-
2500-
2000-
1500-
1
-
5O0-
n
I
IPR EIR MR BNR SIR EBR NGSR
I* Excessive expenditure
on
superior medical
staff.
. ...
Great Indian Peninsular Railway,East Indian Railway
...
Madras Railway...Bengal Najpur RailwaySouth Indian Railway-Eastern Bengal RailwayNizam s State Railway...
Miles.
674
3,338
1,6001.5571,350»99745Employés.
»0,50030,30013.500
8,9008,000
MedicalAdministration,Cost
Per
Mile.
Rs.
31.4030.0».
:
6.50
35-378.9450.18
The democratic idea that every citizen
is
entitled
to the
benefit
of
everything that will
add to
human-health
and
happiness is growing fast. Health and sanitation Acts by theLegislature, medical officers
of
health, sanitary inspectora,inspections
of
workshops, etc., have all,
in
addition
to
pro-longing life and diminishing death, done incalculable serviceby rousing
in the
public mind
the
vague beginnings
of a
tremendously important -mental "procesB
of a
dissipation"
of
Ihre Neugier belohnen
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